Access to and Utilization of Modern Contraceptive Methods

Services in Bangladesh: A Mixed Method Study

SUBMITTED TO
Md. Syful Islam
Assistant Professor
Department of Population Science
Jatiya Kabi Kazi Nazrul Islam University

SUBMITTED BY
Group–3
SL. No Name Roll No
01 JASRIN AKTER 221237701
02 SONIA AKTER 221237702
03 SANZIDA FERDOUS 221237707
04 MD. BADSHA ALAM 221237718
05 MD. JUNAYETH BHUIYAN 221237719
06 JOHNY MIA 221237722
07 MD. AFSHA SHARIYAR ASHIK 221237727
08 S.M. ASHIQUE MAHMUD 221237728
09 SAMIUL ISLAM 221237733
10 HASNAT MD. YOUSUF 221237741

Session: 2021-22 (MSS)

Department of Population Science
Jatiya Kabi Kazi Nazrul Islam University

DATE OF SUBMISSION: 21 SEPTEMBER 2023

 Table of Contents
Table of Contents.......................................................................................................................1

1. Background of the study........................................................................................................2

2. Review of literature................................................................................................................3

3. Statement of problem and justification of this study.............................................................5

4. Objective of the study............................................................................................................6

4.1 Specific Objectives...........................................................................................................6

5. Expected outcomes.................................................................................................................7

6. Study design...........................................................................................................................7

6.1 Quantitative study.............................................................................................................7

7. Outcome variables..................................................................................................................8

8. Explanatory variables.............................................................................................................8

9. Statistical analysis..................................................................................................................8

11. Qualitative exploration.........................................................................................................8

12. Ethics approval and consent to participate...........................................................................9

13. Strength and limitation.........................................................................................................9

14. Proposed schedule..............................................................................................................10

15. Proposed budget.................................................................................................................11

16. Bibliography.......................................................................................................................12

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1. Background of the study
“Reproductive health is a state of complete physical, mental, and social well-being and not
merely the absence of disease or infirmity, in all matters relating to the reproductive system
and its function and processes” (World Health Organization). It is a crucial part of general
health and an essential feature of human development. Family planning was introduced in
Bangladesh in the early 1950s. It is a major component of reproductive health. The literal
meaning of the term family planning stands as the prevention of unwanted pregnancies.
Access to contraceptives is a basic reproductive right to determine the number and spacing of
children. It has become a rising public health issue worldwide (Subedi et al., 2018) .
Contraception is a method or technique which is usually used to control birth. It refers to the
use of various methods to limit the number of children. The use of contraception ensures
individuals or couples prevent unwanted pregnancies (Khan et al., 2021). There are two
categories of contraceptive methods: modern and traditional. Oral pill, male and female
sterilization, intrauterine devices (IUD), implants, injectables, emergency contraception, and
the lactational amenorrhea method (LAM) are examples of modern methods (Mulatu et al.,
2020).

According to the United Nations (UN) 2021, approximately 64.4% of women of childbearing
age (15-49 years old) globally use different methods of contraception. Almost 60% of women
of reproductive age use family planning (WHO). There is evidence that contraceptive use has
increased worldwide, particularly in Asia (62%), Latin America (67%), and sub-Saharan
Africa, which increased by only 20% each (Tolefac et al., 2018). Globally, the number of
women of reproductive age meeting their family planning needs with modern contraceptive
methods has increased (SDG indicator 3.7.1). The most popular contraceptive technique
worldwide is female sterilization (23%), followed by male condoms (22%). Female
sterilization has 219 million users and male condoms 208 million. IUDs (161 million) and the
pill (100 million) are also used worldwide (150 million). Injectables, implants, and male
sterilization have less users worldwide (17 million). 33 million women use rhythm and 53
million withdrawal as traditional ways (Meeting the Changing Needs for Family Planning:
Contraceptive Use by Age and Method, 2022).

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Ensuring that all people have access to their preferred method of contraception promotes
many human rights, including the right to life and liberty, freedom of opinion and expression,
and the right to work and education. Contraceptive use is essential to the well-being of
individuals, families, and communities. Despite all these gains, contraceptive use remains
low in many parts of the world, increasing the number of unwanted pregnancies and unsafe
abortions. Across the Asian continent, contraceptive use is greatly influenced by a variety of
religious and cultural factors. Furthermore, there are differences in reproductive choices
among Asian youth (Pachauri & Santhya, 2002).

Bangladesh is a developing country in Southeast Asia. It is a small country with a large

population. The population of this country is increasing rapidly every day. Although it is not
a developed country, it has made great progress in reproductive health in recent years.
Contraceptive use prevents pregnancy-related health risks for women and adolescent girls.
However, to date, no systematic research has been conducted to find out about their
contraceptive care and the factors that are associated with the services use using mixed-
methods design. Therefore, this study aims to explore the modern contraceptive methods use
and the common barriers to the use of the services among reproductive-aged women in
Bangladesh.

2. Review of literature
(A. Z. Islam et al., 2016) in their research titled “prevalence and determinants of
contraceptive use among employed and unemployed women in Bangladesh” aimed to
determine the factors that influence contraceptive use among the selected women. They used
cross-sectional study and logistic regression to analyze the demographic factors of
contraceptive use. The results conclude that the rate of contraceptive use is higher among
employed women compared to unemployed women which is 67%. They also identified a
limitation in using contraceptives among employed and unemployed Women.
According to (Hossain et al., 2018) “Identifying factors influencing contraceptive use in
Bangladesh: evidence from BDHS 2014 data” explored the prevalence of contraception use
by currently married women of reproductive age or their husbands is 62.4%. The study finds
that contraceptive use is highly influenced by socio-demographic factors. Here, 54% of
women were using modern methods of contraception and only 8% were using traditional
methods. Among the entire contraceptive methods oral pill is the most used method and is
27%.

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(N. Kamal, 2000) in the study entitled “The influence of husbands on contraceptive use by
Bangladeshi women” aimed to find out the socio-economic correlation of contraceptive use
in rural Bangladesh. For this study, they used nationally representative BDHS data, 2004. In
their study, they identified the husband’s opinion of family planning on their current or future
use of modern contraception to limit their children. The results indicate that the prevalence
rate contraceptive use among currently married women non-pregnant women was 61%. The
prevalence of modern methods was 49%. The oral pill and periodic abstinence were the most
preferred modern and traditional methods respectively. Most Bangladeshi women are highly
influenced by their partner in case of family planning issues. As Bangladesh is a traditional
society most women are directed by their husbands in every step of life.

(Huda et al., 2017) in their study on “Contraceptive practices among married women of
reproductive age in Bangladesh: a review of evidence”, wanted to investigate the
contraceptive practice among married women. The purpose of this study was to develop
country profile reports that provide a general overview of the current situation of
contraceptive use status among married women in Bangladesh. In their study, they found that
long-acting contraceptive methods decline over the past few decades. Short-acting
contraceptive methods remain alarmingly high that is at least 36% among married women in
rural Bangladesh.

(S. M. M. Kamal & Islam, 2010) in their study titled “Contraceptive use: Socio-economic
correlates and methods choices in rural Bangladesh” aimed to examine the current use of
contraceptives and methods choice and the associated factors among women in rural
Bangladesh. They used secondary data from BDHS and binary logistic regression techniques
for statistical analyses purpose. They conducted in this study the contraceptive prevalence
rate among currently married non-pregnant women was 61%. Here, modern methods are used
by 49% of women. It is concerning that most of the rural women were uneducated and they
preferred to use the oral pill.

(M. K. Islam et al., 2020) conducted a study entitled “Regional variations of contraceptive
use in Bangladesh: A disaggregate analysis by place of residence”. The objective of their
study was to examine the regional variations in contraceptive use among reproductive age
women. They used secondary data from BDHS, 2014. They considered socio-demographic

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and cultural factors based on rural and urban areas. Their findings identified a significant
regional variation in using contraceptives. The results showed that the odds ratio of
contraceptive use was higher among women who resided in rural areas.

(S. M. M. Kamal, 2015) conducted a study on “Socio-economic factors associated with

contraceptive use and method choice in urban slums of Bangladesh”. This study aimed to
explore the socio-economic factors affecting contraceptive use among women of urban
slums. He used secondary data from Bangladesh Urban Health Survey (BUHS), 2006. The
findings of his study revealed that the contraceptive prevalence rate among women in slum
dwellers was 58.1%. Among all respondents, 53.2% of women used modern methods of
contraceptive.

(Mohammed et al., 2014) conducted a community-based cross-sectional study entitled

“Determinants of modern contraceptive utilization among married women of reproductive
age group in North Shoa Zone, Amhara Region, Ethiopia”. The objectives of their study were
to assess the prevalence and determinants of modern contraceptive utilization among married
women of the reproductive age group. They used primary data and both bivariate and
multivariate logistic regression. Their findings showed that 49.9% of currently married
women used modern contraceptives. Multiple logistic regression models emerged that the
income of the family and the number of living children were significantly associated with
modern contraceptives.

(Mulatu et al., 2020) conducted a study on “Modern Family Planning Utilization and Its
Associated Factors among Currently Married Women in Rural Eastern Ethiopia” this study
was aimed at assessing modern family planning method use and its determinants among
women of reproductive age in the rural districts of Eastern Hararghe zone. Despite
widespread community knowledge of modern contraceptive methods, this study found that
modern family planning utilization in the study area was very low. According to the findings
of the study,18.4% of study participants used modern family planning.

(Kamruzzaman & Hakim, 2015) conducted a study on "Family Planning Practice Among
Married Women Visiting Primary Health Care Centers in Bangladesh," using simple random
sampling on 350 married women attending basic health care facilities in different regions of
Bangladesh. 32.57% of women between the ages of 31 and 35 were aware of family

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planning, 87.71% had heard of contraceptives, 82.57% condom, 76.29% IUCD, and 41.13%
implant, and 20% of women used pills, 4.29 % condoms, and 10% injections in defense of
15.71 % of husbands' approval.

3. Statement of problem and justification of this study

Family planning is one of the major issues in low and lower middle income countries
(LMICs) including Bangladesh, where poor maternal and child health care services are
practiced. Contraceptive use averts maternal deaths by reducing the chance of pregnancy and
the associated complications ,lowering the risk of having an unsafe abortion, reducing infant
mortality, helping to prevent HIV/AIDS, preventing pregnancy-related health risks in
women, reducing adolescent pregnancies, and slow population growth .Majority of the
women are aware of several family planning methods but they often do not know about the
correct use of methods and have misconceptions or fears about side effects. Although the
contraceptive prevalence rate has increased, it is offset by discontinuation, switching and
incorrect use. The method mix is predominated by short-term methods like oral pills,
injectable, male and female condoms, emergency contraception etc. with a consistent decline
in the use of long acting and permanent methods such as intrauterine contraceptive device
(IUCD), female and male sterilization, standard day method (SDM), and lactational
amenorrhea method (LAM). Different socio-demographic factors like women’s educational
level, household wealth status, women working status, administrative divisions, place of
residence, religion, husband’s education are significantly associated with contraceptive
use. Unsafe sex is a major risk factor–particularly among women in developing countries like
Bangladesh. Unwanted pregnancy and its consequences necessitate the use of modern
contraceptives to control. Most of the Bangladeshi women have diabetes and hypertension
that are also linked with the use of contraceptive method. So, people having both diabetes and
hypertension are more prone to use traditional contraceptive methods than the modern
contraceptive methods. Limited choice of methods, limited access to services, particularly
among young, poorer, and unmarried people; fear or experience of side-effects; cultural or
religious opposition; poor quality of services; users' and providers' bias against some
methods; and gender-based barriers to accessing services are major reasons of not using
contraceptive methods.

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4. Objective of the study
The overall goal of this study is to assess the prevalence of and determinants influencing
access to modern contraceptive methods use in Bangladesh, with the aim of providing
evidence-based recommendations to improve the utilization of the services and enhance
maternal and child health outcomes in the country.

4.1 Specific Objectives

1. To determine the prevalence of modern contraceptive-methods use among
reproductive-age women in Bangladesh.
2. To identify the factors that influence the use of modern contraceptive methods
adjusted for individual, household, and community-level factors in Bangladesh.
3. To explore the barriers and challenges faced by women in accessing preconception
care services in Bangladesh.
4. To provide evidence-based recommendations for policymakers and healthcare
providers to improve access to preconception care services in Bangladesh.

5. Expected outcomes
The utilization of modern contraceptive methods services is expected to be low in
Bangladesh. This can be attributed to various factors, including socio-demographic
characteristics, women's autonomy, and the level of healthcare facilities. These factors are
likely to be associated with the utilization of modern contraceptive methods in the country.

6. Study design
We will apply a sequential mixed-methods design where quantitative data collection and
analyses will follow by the collection and analysis of qualitative data. The qualitative
findings, therefore, will explain and interpret the findings of the quantitative study.

6.1 Quantitative study

We will use the 2017/18 Bangladesh Demographic and Health Survey data in this study. The

BDHS survey is a nationally representative household survey conducted as part of the

Demographic and Health Survey Program of the USA. The survey selected nationally

representative households through two-stage stratified random sampling methods. At the first

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stage, the survey selected a list of 675 clusters, covering each division of Bangladesh. A total

of 672 clusters was included finally after excluding 3 clusters because of the extreme flood in

Bangladesh. At the second stage of sampling, a fixed number of 30 households was selected

from each selected cluster. Finally, the survey was conducted in 19,457 households with 96%

inclusion rate. There were 20,376 women in these selected households, of them, 20,127

women were interviewed with a response rate of 98.8%. Informed written consent was

obtained from all participants. A sub-sample of reproductive-aged women will analyze in this

study based on the following inclusion criteria: (a) women reproductive-aged (15-49 years),

(b) women who will have at least one live birth in the three years preceding the survey, (c)

women will be being fecund with having had at least one episode of sexual intercourse in the

month prior to survey and (d) not being pregnant or experiencing lactational amenorrhea at

the time of the survey.

7. Outcome variables
Modern contraceptive methods use (yes, no) will be the outcome of interest in this study. To
collect the relevant information for this variable, the survey authority asked women, “Are
you currently doing something or using any method to delay or avoid getting pregnant?”
Women who responded “Yes” to this item were then asked, “Which method are you using?
The list of the methods are: pill, injectable, implant, IUD, condoms, female sterilization, male
sterilization, periodic abstinence and withdrawal. We will include the pill, injectable, implant,
IUD, condoms, and female and male sterilization as modern contraceptive methods and
coded as “yes”, and “no” for contraceptive no use or for use of traditional methods such as
periodic abstinence or withdrawal.

8. Explanatory variables
The variables available in the BDHS dataset will be included and categorized as individual-,
household-, and community level factors. Individual level factors will be maternal age at
birth, maternal education, and maternal formal employment status, total number of children
ever born, and exposure to mass media. Households level factors will be partner’s

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educational status, sex of the household’s head, and wealth quintile. Place of residence and
region of residence will be considered as community level factors.

9. Statistical analysis
Descriptive statistics will be used to describe the characteristics of the respondents.
Multilevel mixed-effect logistic regression model will be used to explore the associations
between outcome variable and explanatory variables. We will use the multilevel mixed-effect
logistic regression model because of the nesting structure of the BDHS data, where
individuals are nested within a household and households are nested within a cluster. In such
nesting data, simple logistic regression model may be producing less estimates, thus
recommending the use of multi-level mixed-effect logistic model. The results will be
included as odds ratios (OR) with its 95% confidence intervals (CI). All analysis will be
conducted using statistical software such as Stata and NVivo.

11. Qualitative exploration

The qualitative data will be collected based on in-depth qualitative interview. Firstly, a
district within the Mymensingh division will be chosen. From this district, a sub-district will
be selected in the second stage. However, the Trishal upazila will be randomly selected. The
qualitative component will be based on in-depth qualitative interview of a subset of 15 newly
married women, and a subset of health care providers (approximately 10). The qualitative
survey will explore the circumstances around underage marriage in the Bangladesh and
access and barriers to utilization of modern contraceptive services. The interviews will be
conducted by persons who can speak both English and Bangla language. The data of
qualitative survey will be analyzed thematically using Nvivo software.

12. Ethics approval and consent to participate

The survey will be analysed with approval by the institutional review board of ICF. Informed
consent will be obtained from all participants. No separate ethical approval will be required
to conduct this study. We will obtain the permission to access this survey and conduct this
research. All methods will be performed in accordance with the relevant guidelines and
regulations

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13. Strength and limitation
This study will have several strengths as well as will face a few limitations. This study will
reveal as the pioneering investigation in Bangladesh of utilizing nationally representative
quantitative survey data. Additionally, a qualitative survey finding will provide insight on the
motivating factors behind the utilizing modern contraceptive methods. The study will employ
with advanced statistical modeling techniques to analyze the data, incorporating a diverse
range of confounding variables. As a result, the reported findings possess sufficient
robustness to inform national-level policies and programs. However, one key limitations of
this study is that the quantitative data analyzed in this study were derived from a cross-
sectional survey, which restricts the ability to establish causal relationships. While the study
will explore various cultural and religious factors associated with utilizing contraceptive
methods through qualitative analysis, these factors were not adjusted for in the quantitative
analysis due to their unavailability within the survey. Regardless of these limitations, this
study will explore the influencing factors of utilization modern contraceptive methods in
Bangladesh.

14. Proposed schedule

Activity Start Data End Data Duration
Project Planning 1st January 2024 15th January 2024 15 days
Literature review 16th January 2024 28th February 2024 42 days
Finalization of research 1st March 2024 10th March 2024 10 days
question and objectives
Hire Project Staff 11th April 2024 31 May 2024 45 days
Training and capacity 1st June 2024 15th June 2024 15 days
Building
Pilot testing 15th June 2024 30th June 2024 15 days

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Methodology 1st July 2024 31th July 2024 31 days

Data management 1st October 2024 15th October 2024 15 days

Data analysis 16th October 2024 10th November 26 days

2024
Report writing 11th November 20th November 10 days
2024 2024
Discussion and conclusion 21th November 5th December 2024 14 days
2024
Submit project’s draft to 6th December 2024 25th December 20 days
reviewers and editors 2024
Project closure 26th December 31th December 6 days
2024 2024

15. Proposed budget

SL No Expenditure Amount (BDT)
1 Project Director Honorarium/ Project Manager 120000
2 Honorarium For Co-Author 30000
3 Research Assistant 70000
4 Field Workers 250000
5 Data Analyst 10000
6 Health Experts/ Consultants 30000
7 Communication (Internet/ Wi-Fi) 25000

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 8 Research materials, Suppliers and Equipment 50000
9 Training cost 10000
10 Travel Expense 100000
11 Fundraising team/collecting team 5000
12 Food cost 80000
13 Report writers 15000
14 Other Expenses 50000
15 Total 8,45,000
16 Total Project Cost in a year (in words) Eight lakh and forty-
five thousand taka only

16. Bibliography
Hossain, M. B., Khan, M. H. R., Ababneh, F., & Shaw, J. E. H. (2018). Identifying factors
influencing contraceptive use in Bangladesh: evidence from BDHS 2014 data. BMC
Public Health, 18(1), 192. https://doi.org/10.1186/s12889-018-5098-1
Huda, F. A., Robertson, Y., Chowdhuri, S., Sarker, B. K., Reichenbach, L., & Somrongthong,
R. (2017). Contraceptive practices among married women of reproductive age in
Bangladesh: a review of the evidence. Reproductive Health, 14(1), 69.
https://doi.org/10.1186/s12978-017-0333-2
Islam, A. Z., Mondal, M. N. I., Khatun, M. L., Rahman, M. M., Islam, M. R., Mostofa, M.

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 G., & Hoque, M. N. (2016). Prevalence and Determinants of Contraceptive use among
Employed and Unemployed Women in Bangladesh. International Journal of MCH and
AIDS, 5(2), 92–102. https://doi.org/10.21106/ijma.83
Islam, M. K., Haque, M. R., & Hema, P. S. (2020). Regional variations of contraceptive use
in Bangladesh: A disaggregate analysis by place of residence. PloS One, 15(3),
e0230143. https://doi.org/10.1371/journal.pone.0230143
Kamal, N. (2000). The influence of husbands on contraceptive use by Bangladeshi women.
Health Policy and Planning, 15(1), 43–51. https://doi.org/10.1093/heapol/15.1.43
Kamal, S. M. M. (2015). Socioeconomic Factors Associated With Contraceptive Use and
Method Choice in Urban Slums of Bangladesh. Asia Pacific Journal of Public Health,
27(2), NP2661–NP2676. https://doi.org/10.1177/1010539511421194
Kamal, S. M. M., & Islam, M. A. (2010). Contraceptive Use: Socioeconomic Correlates and
Method Choices in Rural Bangladesh. Asia Pacific Journal of Public Health, 22(4),
436–450. https://doi.org/10.1177/1010539510370780
Kamruzzaman, M., & Hakim, M. (2015). Family Planning Practice Among Married Women
Attending Primary Health Care Centers in Bangladesh. 1, 251–255.
Khan, M. N., Islam, M. M., Rahman, M. M., & Rahman, M. M. (2021). Access to female
contraceptives by Rohingya refugees, Bangladesh. Bulletin of the World Health
Organization, 99(3), 201–208. https://doi.org/10.2471/BLT.20.269779
Meeting the changing needs for family planning: Contraceptive use by age and method.
(2022). 4.
Mohammed, A., Woldeyohannes, D., Feleke, A., & Megabiaw, B. (2014). Determinants of
modern contraceptive utilization among married women of reproductive age group in
North Shoa Zone, Amhara Region, Ethiopia. Reproductive Health, 11(1), 13.
https://doi.org/10.1186/1742-4755-11-13
Mulatu, T., Sintayehu, Y., Dessie, Y., & Deressa, M. (2020). Modern Family Planning
Utilization and Its Associated Factors among Currently Married Women in Rural
Eastern Ethiopia: A Community-Based Study. BioMed Research International, 2020,
6096280. https://doi.org/10.1155/2020/6096280
Pachauri, S., & Santhya, K. (2002). Reproductive Choices for Asian Adolescents: A Focus on
Contraceptive Behavior. International Family Planning Perspectives, 28.
https://doi.org/10.2307/3088221
Subedi, R., Jahan, I., & Baatsen, P. (2018). Factors Influencing Modern Contraceptive Use
among Adolescents in Nepal. Journal of Nepal Health Research Council, 16, 251.
https://doi.org/10.3126/jnhrc.v16i3.21419
Tolefac, P. N., Nana, T. N., Yeika, E. V., Awungafac, N. S., Ntsama, Y., & Njotang, P. N.
(2018). Trends and patterns of family planning methods used among women attending
family planning clinic in a rural setting in sub-Sahara Africa: the case of Mbalmayo
District Hospital, Cameroon. BMC Research Notes, 11(1), 541.
https://doi.org/10.1186/s13104-018-3658-1

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